On March 30th, President Obama signed the final piece of healthcare reform legislation concluding an epic battle that ultimately lead to the passage of the Patient Protection and Affordable Care Act (PPACA). The bill enforces the largest change to US healthcare for decades and has provided an opportunity for Complementary and Alternative Medicine (CAM) advocates to be federally endorsed in our future healthcare system. This entry is an attempt to present excerpts from the PPACA itself that could lay the groundwork for incorporating CAM into the future healthcare system.

CAM proponents tout a few sections in the PPACA as a victory for their cause. One of these sections is 3502, entitled Establishing Community Health Teams To Support The Patient-Centered Medical Home, which endorses government grants “to establish community health teams,” which are defined as “community-based interdisciplinary, interprofessional teams.” It goes on to say that such a ‘team’ may include, “doctors of chiropractic, [and] licensed complementary and alternative medicine practitioners.”1

The requirements of such a health team are listed and one of them reads, “to provide support necessary for local primary care providers… [and] to provide coordination of the appropriate use of complementary and alternative (CAM) services to those who request such services.” What this entails, is that there will be an influx of federal spending into CAM services with the enactment of the new bill.

Fortunately, the section provides other requirements for ‘health teams’ such as,

to support patient-centered medical homes, defined as a mode of care that includes… safe and high-quality care through evidence-informed medicine, appropriate use of health information technology, and continuous quality improvements.

Health teams will also be required to (bear with me here),

provide support necessary for local primary care providers to… provide quality-driven, cost-effective, culturally appropriate and patient- and family-oriented healthcare… [and] collect and report data that permits evaluation of the success of the collaborative effort on patient outcomes, including collection of data of patient experience of care and identification of areas for improvement.

This could mean that, although CAM will be supported by our federal plan, there will be some restrictions in place requiring it to adhere to an ‘evidence-informed’, ‘quality-driven’ and ‘cost-effective’ form of medicine. Guidelines may be implemented to track the progress and efficacy of health teams using CAM therapies. If this were true, I would suspect an initial rise in government-funded CAM but a downfall in the long run. A new surge of government-sponsored data should separate cost-effective treatments from sham if CAM therapists are held to such standards.

Unfortunately, the government has a poor track record of declaring therapies ineffective. Nowhere has this been more obvious than in The National Center for Complementary and Alternative Medicine (NCCAM), which has been criticized for spending hundreds of millions of tax dollars on studies of CAM and never confirming the efficacy of a single therapy nor declaring any as ineffective. This shows that federally funded data gathered about CAM might similarly never actually lead to meaningful conclusions or changes in our healthcare. If this were true, CAM incorporated into the healthcare system would stay for the ride regardless of its efficacy and cost-effectiveness.

Another section of the PPACA, supported by herbalists, is number 4206: Demonstration Project Concerning Individualized Wellness Plan[2]2. The section describes the establishment of “a pilot program to test the impact of providing at risk populations an individualized wellness plan… that is designed to reduce risk factors for preventable conditions.” The program will include nutritional counseling and will provide dietary supplements that have health claims approved by the FDA. Examples include calcium supplementation for those at risk of osteoporosis and prenatal folic acid to decrease the incidence of neural tube defects. Seeing as this is guided by the FDA’s recommendations I can only join in with the approval of such a “wellness plan”, and expect it to be a big hit in the new healthcare system. Since herbalists see this as an opportunity for the government to incorporate their therapies into these wellness plans, I hope that the program will continue to adhere to FDA recommendations, especially if it is approved for wide-scale use.

On other fronts, chiropractors have found a niche in the soon-to-be National Healthcare Workforce Commission as described in section 5101 of the PPACA. “The Commission,” as it is referred to, will be responsible for analyzing and disseminating information to the federal government, state and local agencies, Congress, healthcare organizations, and professional societies about the US healthcare workforce. It will develop “evaluations of education and training activities to determine whether the demand for healthcare workers is being met.”

In so doing, it will recommend to the government which institutions deserve grants in order to “develop a fiscally sustainable integrative workforce that supports a high-quality, readily accessible healthcare delivery system that meets the needs of patients and populations.” It will also “study effective mechanisms for financing education and training for careers in healthcare.” Put more simply: the Commission will be channeling tax dollars to different healthcare institutions based on their analysis of demand in our healthcare system.

The Comptroller General, Gene L. Dodaro, will appoint the members of the Commission no later than September 30th of this year. It will consist of 15 members representative of the healthcare workforce, employers, third-party payers, representatives of consumers, State or local workforce investment boards, and educational institutions. It seems like there will be a host of different viewpoints and interests influencing the recommendations that this commission will be making.

Therein lies the problem. The section about the Commission specifically defines the ‘healthcare workforce’ as, “all healthcare providers with direct patient and support responsibilities,” and specifically includes licensed CAM practitioners and chiropractors within the definition. If proponents of such CAM therapies infiltrate the Commission, taxpayers could end up funding disproportionate amounts of money to medical institutions unsupported by science.

Another section of the PPACA that has been hailed as a victory by CAM proponents, especially chiropractors, is section 27063, which prohibits health insurance discrimination against any “health care provider who is acting within the scope of that provider’s license or certification under applicable state law.” Chiropractors, who feel that they are being ‘discriminated’ against within the medical community, see this as an end to their problems. Interestingly, section 2706 is colloquially dubbed the “Harkin amendment”, after it was introduced by the Iowa Senator himself. David Gorski has written about him on a number of occasions. Tom Harkin is the man most responsible for the creation of the aforementioned NCCAM and also the Dietary Supplement Health and Education Act (DSHEA) of 1994, which allows “herbal supplement” manufacturers to make dubious health claims with little or no regulation.

The section itself is simply entitled Non-Discrimination in Health Care and prevents insurance companies from discriminating against particular medical modalities. At first glance this seems like a free pass for CAM, especially with the American Chiropractic Association s (ACA) claims that the inclusion of this provision has “potential for positive, long-range impact on [their] profession and the patients [they] serve.” But the provision itself makes a point to address that, “nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary [of Health & Human Services] from establishing varying reimbursement rates based on quality or performance measures.”

If this provision is calling for an end to discrimination of health modalities that is not based on quality or performance, than I don’t understand why CAM proponents are so happy about this. Don’t they understand that it’s their quality and performance that is under scrutiny and that these characteristics are determined by science? It’s as if the ACA believes the main reasons they are ‘discriminated against’ are not based on evidence at all. I actually agree with the proposition that heath care modalities shouldn’t be discriminated against for unscientific reasons.

On a more positive note, the PPACA bill has in it a section on immunization 4and describes a new program that will come into effect to maximize vaccinations throughout the country. This is a huge blow to the anti-vaccine movement, which has been surprisingly quiet about this. Hopefully, it will help more patients to be vaccinated, especially those without the resources to do so.

In summary, we should be prepared for an infiltration of CAM therapies into the new healthcare system that will come into effect starting this year. The PPACA healthcare bill is not a disaster for science-based medicine by any means but it is not bulletproof either. The bill specifically mentions its endorsement of CAM and the more it acts on this, the more difficult it will be to eradicate passionately advocated therapies with no evidence supporting them in the years to come. Now is the time to ensure that the US healthcare system does not begin to excessively promote sham therapies. Otherwise, we will risk developing a new foundation to our healthcare system that incorporates scientifically unsound medicine.

ABOUT THE GUEST BLOGGER: Matt Roman is a Polish-American, who immigrated to the Unites States in 1985 and studied neuroscience and chemistry at Franklin and Marshall College. He is currently enrolled as a medical student at Jagiellonian University in Cracow, Poland. His interest in complementary and alternative medicine began with his involvement in courses and research at The Institutes for the Achievement of Human Potential in Philadelphia before he became immersed in the skeptical movement and a science-based approach to medicine. He hopes to specialize in internal medicine in the United States and enjoys blogging about a diverse range of general science topics. A different version of this post first appeared on the blog Science-ology in March 2010.

70 thoughts on “CAM in “Obamacare””

Hey, what could go wrong with that whole ‘regulation’ thing, huh? (“Regulatory capture”? Wazzat? You got a study or empirical evidence that that exists? Bah, balderdash!)

All we need is better laws, and more of them! Venceremos, Comrades, venceremos!

I can’t wait until Cde. Gorski is standing tall in front of a board consisting of two naturopaths, a chiropractor, and two MDs to justify his latest grant proposal. Maybe that will put a dent in his faith in regulatory control of medicine. >;->

At first blush this looks like a disaster for SBM, but in the long run if the stipulations about high-quality and evidence-based interventions are followed through it may help the sCAMmers bury themselves.

Having said that, there is no evidence that politicians and bureaucrats are able to tell good evidence from bad…

This draws up the battlelines for some trench warfare in the implementation phase.

In my opinion, the health care changes are fatally flawed if they are only about money, and about who gets the biggest slice of the pie.

Mainstream medicine is not immune from the lure of money. In fact, the newest technologies are enormously expensive. If a patient can get satisfaction from a cheap placebo, instead of a multi-thousand dollar high-tech gizmo, why not?

However, the best health care is still prevention, based on a healthy diet and lifestyle. If more people would make better lifestyle choices, the cost of health care would drop drastically.

All of the arguments over money, and all the name calling, don’t help people make better choices at the supermarket.

Matt is right: now is the time for everyone to get active and ensure only evidence/science-based treatments are covered and money is not wasted on ineffective ‘therapies’.

We are making progress in the UK, slowly getting rid of nonsense like homeopathy from our National health Service and tightening up on claims chiros are allowed to make (particularly with the announcement of the death of the subluxation), but it’s far easier to stop it getting in in the first place that it will be to remove it once it’s gained a foothold.

In my home province, we’ve instituted Family/Community Health Teams, and they work remarkably well. The teams are required to follow evidence-based practice.

In terms of who is hired for the Health Team, clinic administration makes application for funding for specific practitioners; but this is done in consult with the physicians to find out what medical professionals would be most useful to the practice.

Most teams include several GPs, nurses, and a nurse practitioner or two: Ours also includes a pediatrician, a part-time pharmacist, a dietitian, and a mental health worker. None have a chiropractor, naturopath, or bump-readers.

In the end, the administration makes decisions based both on local needs (sometimes an addictions counselor instead of a mental heath worker or a geriatrician instead of a pediatrician) and where they can get the most healthcare benefit for their budget. While I have no doubt that local chiropractors would love to get in, it isn’t likely that the clinic would be willing give up a pediatrician or an NP to gain one. And I (for one) would fight tooth and nail to prevent it.

It isn’t actually as messy as it sounds, and the quality of care is excellent. Electronic medical records ensures that everyone communicates around patient care, and hall-way consults between the professionals are common.

In terms of institutionalizing woo, I would say that the big question should be around how decisions are made about which professionals to hire, but it makes sense to follow local need and physicians’ practice requirements.

“If a patient can get satisfaction from a cheap placebo, instead of a multi-thousand dollar high-tech gizmo, why not?”

And if the satisfaction is short lived and the patient dies when he could have had a chance with something that can actually work rather than just make him feel satisfied for a while?
(Of course that’s only one argument against this mistaken attitude)

“If more people would make better lifestyle choices, the cost of health care would drop drastically.”

People still die eventually, and 90% of health care costs are for people during their final illness. Prevention is good but it is not a cheaper alternative, it is an additional cost.

BillyJoe – “People still die eventually, and 90% of health care costs are for people during their final illness. Prevention is good but it is not a cheaper alternative, it is an additional cost.”

BillyJoe – I’ve always suspected that about the proportion of health care, but never had time to find a source. Do you know where you got that information? It would be useful to me in an ongoing dispute.

“People still die eventually, and 90% of health care costs are for people during their final illness.”

So what is the goal? Is it to maximize the total number of heartbeats in every human life or is it to maximize the quality of life or is it to maximize the flow of dollars into the pockets of healthcare providers (please, I am not attacking physicians in general or hospitals or insurers).

We routinely wheel out heroic procedures in the face of certain death … as long as the insurance holds out. I have personally seen a fem-pop bypass performed on an ancient woman, long lost to the mists of dementia, who spent her days curled in the fetal position. And more often than not it is the patient or family pushing for these procedures. Who wants to be the family member who killed grandma?

The fraction of GDP that a people will spend for healthcare has some limit. Wouldn’t those dollars be better spent fighting childhood diseases, battling diabetes or searching for cures for cancers? I’m all for not going quietly into that good night but haven’t we taken it to an extreme?

For everyone who sees this as hope that CAM will be either tested and dropped or proven and adopted, I feel for you but expect you will be disappointed. CAM appears to be teflon-coated when it comes to avoiding criticisms and dodging evidence. It’s medical religion, and faith always stomps reason to a pulp when you’re talking about the general public.

Too bad you are so easily turned off. Obamacare, Reaganomics, and so forth are commonly recognized shorthand for complex programs. Using those terms avoids rehashing the difficult and often polarizing details of those policies and cuts right to the detail at hand.

If language is politics then there musn’t be much that doesn’t turn you off.

And others like mocking Obama. And personally, I think they’re mostly all self-absorbed, intellectually shallow, dishonest slime; the pigs of Orwell’s Animal Farm regardless of their political persuasion.

But how does your liberal bent or SD’s conservative bent or my frank disgust with them all advance the human condition? One presumes that we all would like a community organized to afford everyone an opportunity to live a happy and meaningful life. And yes, that is as true of the conservatives that I know as it is of the liberals.

How then do we best achieve that goal? At SBM the bloggers take the position that SBM is the most efficient way to deliver quality health care to the community. I would heartily agree. Obamacare, as it was used in today’s headline, wasn’t in any way pejorative. I guess I don’t understand your objection.

One presumes that we all would like a community organized to afford everyone an opportunity to live a happy and meaningful life. And yes, that is as true of the conservatives that I know as it is of the liberals.

He’s probably just too sensitive to any potential mocking of Obama. In my opinion, this is not health care reform anyway and refuse to refer to it as HCR. This was enacted by arrogant politicians who pretend to have knowledge that is superior to those that are in the trenches. That’s why you end up with the family demanding their 99 year old parent gets dialysis, fem-pop bypasses, etc. They are simply using us as enablers in this torture, while the taxpayer foots the bill. And since it’s coming to the point that less than half is actually paying the taxes? What the hell? Go for it.

“Obamacare, as it was used in today’s headline, wasn’t in any way pejorative. I guess I don’t understand your objection.”

In reading blogs and news article comments, I have most often seen “Obamacare” used by the “Obamacare will kill your granny” set. Actually, I kinda did a double take when I saw it here. (Stewart had a good bit on “Obamacare” when he was interviewing John O’Hara – tea party author.) So I would say that the word carries a derisive history that I would want to be aware of as a writer.

Reaganomics. I don’t recall that being used by the opposition. I recalled the liberals often called it “Trickle Down” I thought Reaganomics was kind of honoring Reagan’s popularization. But that’s a bit before my time, could be wrong.

I guess when I saw the use here, I kinda wondered at the intent of the author.

Nowhere has this been more obvious than in The National Center for Complementary and Alternative Medicine (NCCAM), which has been criticized for spending hundreds of millions of tax dollars on studies of CAM and never confirming the efficacy of a single therapy nor declaring any as ineffective.

I wonder: over a comparable period of time, for a comparable amount of funds, how many therapies has the non-CAM side of NIH confirmed or rejected? After all, hundreds of millions of dollars sounds enormous, but pharma routinely spends that much on single drugs without reaching a conclusive endpoint. Obviously, the kinds of studies NIH sponsors aren’t very comparable to a pharma development program, but it leads me to wonder: what should we have expected from NCCAM if they were as productive as the NIH average?

Don’t get me wrong – I think the money NCCAM spends on crap like homeopathy and energy healing is a deplorable waste. I’m just wondering whether the quoted criticism is realistic.

Yes, I absolutely do believe that. Most people want to be sure they get a nice scoop for themselves. But most people are also smart enough to recognize that a rising tide works to their benefit. That is the foundation on which the entire free market system rests.

That is rather different than believing that everyone is overflowing with altruism.

Agreed. Health care reform is horrifically complex. What I’ve seen so far looks like a rather cynical transfer of wealth to my generation (aging Boomer) from future generations. This will carry with it unintended consequences. For instance healthy young people may eschew expensive health coverage and use that money for down payments on homes and to buy goods and services. Reshuffling this money will impact other sectors of the economy.

I hope that real and meaningful reform comes. But I think it will have to be done in discreet steps. And I also think there will have to be some readjustment of expectations about levels of health care to be delivered, especially as we each approach our point of diminishing returns.

“O yeah? Well I read “Reaganomics” as pejorative always too. Still don’t know how to do a smiley emoticon.”

The difference here, if I’m recalling correctly is that Reaganomics was coined (positively) by conservatives, and “Hillarycare” was coined as a pejorative to tie the legitimate need for health care reform to a person they loathed. Eventually, “Hillarycare” became “Obamacare”, and the media, in borrowing the talk radio talking points perpetrated the phrase, tying HCR to him, and him alone, as if this was an act of ego or narcissism and not something necessary for all Americans regardless of political leanings.

The phrasing has negative connotations, whether you wish to admit to them or not. The greater media acceptance of the term has not neutralized its origins. and tying the fate of all Americans to a single personality is not helpful to any of them.

@windriven
“But most people are also smart enough to recognize that a rising tide works to their benefit. That is the foundation on which the entire free market system rests.”

Extraordinary Popular Delusions and the Madness of Crowds would do you a world of good.

The foundation of the “truly free market system” involves fads and other methods to exploit the people not forward thinking or concerned enough to work in their own benefit in their need for immediate satisfaction. “Smart enough” individually is a useless abstraction and misses the context of why people are taken-in by CAM. It also ignores the lobbyists behind the scenes.

“Pretty much I turn off when someone uses the term “Obamacare”. Language is politics.”

As a person who makes a living in branding, I’m with Ian on this one. People take a lot of care in coining and disseminating brands like “Obamacare,” betting that many will take the position windriven has and defend it as neutral shorthand.

Polls consistently show that the public will respond more negatively to poll questions which evoke a president’s name, regardless of who the president is, and since opponents styled the bill as a government takeover of healthcare, “Obamacare” is ideally suited to its task. The word is pejorative by design.

That being said, interesting article. I was curious as to how PPACA would address CAM. It looks like for the most part, that remains to be seen.

“[a]nd “Hillarycare” was coined as a pejorative to tie the legitimate need for health care reform to a person they loathed.

My but don’t you enjoy sweeping certainties? Mightn’t one argue that the Clinton era effort at health care reform was dubbed Hillarycare because the panel was overseen by Hillary Clinton? The fact that you take the term as a pejorative says … well, I’m not quite sure what it says about you.

“The foundation of the “truly free market system” involves fads and other methods to exploit the people not forward thinking or concerned enough to work in their own benefit in their need for immediate satisfaction.”

Yes, you’re right. Command economies have done far more to enrich the lives of humans than have free market economies (is there an emoticon for rolling eyes???). Maybe you ought to put down socio-economic comic books like those you mentioned and study history and economics.

Well I guess I’m not an aging boomer. Missed that definition by a year. I think that makes me genX (which just sounds too cool for my age.) I’m reasonably sure that the new HCR has it’s flaws, but I am primarily happy that if all goes as planned, when my son reaches the age where we can’t cover him by our insurance he will able to buy insurance if needed at the going rate, rather than being outright declined or charged exorbitant rates because of his congenital conditions. Also happy that if my husband lost his job/insurance and one or both of us had to start contracting, we would be able to get private insurance for my son along with the rest of the family.

Who know, maybe if those features had already been in place, I would not have support HCR so much. But, I also believe when flaws are found they can be dealt with. Maybe they could even be dealt with intelligently, if we’re not all dicks about it.

While we’re getting all linguistically picky on people: I read “Obamacare” as pejorative. Always.

Out of curiosity, why?

I do not automatically view such terms as perjoratives, anymore than I regarded “Reaganomics” or “Romneycare” (the term after which “Obamacare” was modeled) as a perjorative. They’re convenient shorthand names based on the person who originated the policy or in whose name the policy was executed. I will admit that “Hillarycare” was a perjorative, but that was because it was primarily used by her political enemies, whereas Obamacare seems to be used by the press a lot, and not just the right wing press.

Heck, even President Obama used it himself on at least one occasion, at least acknowledging its existence:

I have to agree with many others: Obamacare is perjorative. Why? Because health care reform is intentionally tied to him (rather than Congress) in an attempt to diminish its benefits. Now, I don’t think most people realize they are doing that when they use the word, but it definitely has that effect.

Thanks for covering this topic. I’ve been wondering about CAM in the new health care law, but was too lazy to look it up. Needless to say, I have zero faith in the government’s ability to regulate CAM, especially given certain lawmakers campaign contributions. I’m also highly skeptical of the law regarding conventional medicine as well.

“Because health care reform is intentionally tied to him (rather than Congress) in an attempt to diminish its benefits.”

I’m not sure how tying HCR to Mr. Obama diminishes its benefits. Would it somehow have greater benefits if it was styled Pelosicare or Reidcare? The president drove healthcare reform. I fail to see how attaching his name to it is in any way pejorative. But then I still fail to see Hillarycare as pejoritive. Perhaps I lack finely honed political sensitivities.

I think it’s probably impossible to use only words that are not emotionally charged for at least someone. If I see “Obamacare” and I react to it, either positively or negatively, it says more about me than the speaker. Does my reaction to it prevent me from considering another point of view and learning something? Does it just confirm my own biases and allow me to uncritically accept the message?

“With that in mind, I’d love to hear Matt Roman’s thoughts on what average citizens can do to help the healthcare reform move away from CAM.”

Maz, I think the best and only thing to do right now is to be aware that this is fresh ground for CAM advocates. Such people often are sneaky and attempt to slide in under the radar when no one is looking. This article was meant to alert people out there that there is potential for abuse with the influx of federal spending into Obamacare.

Yes, I said it. OBAMACARE! I only am using this term to grab the attention of those discussing its semantics.

Personally, I agree that the term “Obamacare” has had some partisan tones to it. If you see my original article from March, the title was different. Nowhere in the body do I refer to healthcare as Obamacare. The title of this article was switched to make it catchier and to increase viewers. Since this is my first post on here, it helps get me out there.

For the record, although I can see how people would think otherwise, there was no intent to put any negative connotations into the title of the article.

“I think it’s probably impossible to use only words that are not emotionally charged for at least someone. If I see “Obamacare” and I react to it, either positively or negatively, it says more about me than the speaker. Does my reaction to it prevent me from considering another point of view and learning something? Does it just confirm my own biases and allow me to uncritically accept the message?”

Put it this way: labeling health care reform “obamacare” is a distraction from the real issue. It makes it about him and not health care. The whole reason partisans started calling it that was to evoke an emotional response from people who hate Obama. I don’t think a single Republican has voted for anything Obama has proposed or advocated sometimes purely because it comes from him. If we’re trying to purely talk about the effects of CAM in the new health care reform law, we’d refer to the title in neutral language. I don’t have a problem with the title myself, but it certainly it not a neutral title (but I thought it was a pretty neutral article, clearly the author is not a partisan, at least not here). More likely it’s just a catchphrase.

“… tying HCR to him, and him alone, as if this was an act of ego or narcissism and not something necessary for all Americans regardless of political leanings. … tying the fate of all Americans to a single personality is not helpful to any of them.”

Alright, enough with perseveration and, as Alison so accurately described it, linguistic nitpicking over the term “Obamacare” already! Please!

It’s peripheral at best to the topic of the post, at best a distraction. Please stick to the meat of the topic, which is what the effect of the recently passed health insurance reform law will be on whether insurance companies will be forced to promote or fund CAM. I’m sorry I even asked.

I think we will somehow muddle through this, but this is purely wishful thinking. We have been lucky so far in this country. Will continued funding be based on solid science or wishful thinking? If left to politicians, I fear the worst.

“Yes, you’re right. Command economies have done far more to enrich the lives of humans than have free market economies (is there an emoticon for rolling eyes???). Maybe you ought to put down socio-economic comic books like those you mentioned and study history and economics.”

The book I mentioned *IS* history and economics, and I suggest you read it.

Unfettered free market capitalism is exploitative. That is something to always take into account, and not an endorsement of planned economies.

Topically, you can expect the free market to potentially come across great medical technology and breakthroughs, but you can’t expect it to promote science and the well-being of the populace. If the free-market “worked” in that manner, CAM would not exist.

Part of the problem with Obamacare, that may lead to the persistence of CAM, is not facing the economic reality of health care. Economics, in my lay understanding, is about choices. In regards to health care, it allows you to pick any 2 out of the following: inexpensive, accessible, effective(ie science based). The politicos seem to be promising all three.

“I seem to get inexpensive, accessible and effective health care. But what would I know?”

I don’t have much opinion on the quality of Canada vs U.S. health systems.

But I did wonder. One of the mom’s in our Cleft Lip and Palate group is from Canada. She’s a NP and has insurance through her work here in the U.S. She said she has considered moving back to Canada, but felt her son was getting better care for the CLCP here.

I didn’t have the opportunity to get a good explanation of why. I know one thing that is common here is Surgeon/Hospital shopping, meaning we got our insurance cover specifically for the Surgeon/Hospital we wanted to use. It costs extra, but we’ve been very happy with them so far.

The other thing that is a concern with adoptive parents with CLCP is scheduling. Better results come with earlier surgeries, so having to wait months for a appointment can be detrimental.

First, remember that ALL DOCTORS ARE ON-NET ALL THE TIME FOR EVERYONE. That’s what universal health insurance means. I have more choice than you do.

What an American might mean when they are fretting about not having their choice of doctors is that they can’t self-refer to a specialist. If I think I have a health problem I see my GP. If she wants a specialist’s input – or to refer me to a specialist for ongoing care – she refers me. If I don’t like that particular specialist I can ask to see another one. Not being able to self-refer to a specialist doesn’t seem to be a big deal to me.

(Actually, we can and sometimes do self-refer to specialists. I have, myself. Practically what happens is that because of our reimbursement schedules we don’t have as many specialists as you do and a cardiologist simply isn’t motivated to work up any random person who walks in off the street. They want to know that their patients have been qualified as actually having a use for their services.)

(And not all doctors are on-net either: a few take no insurance at all and don’t have hospital privileges. Instead they do housecalls and take cheques.)

Alison – Thanks for your run-down on the Canada system. I have heard some of the stats on spending and quality of different systems. NPR did a series awhile back. But, I’m always curious about personal experience in the different systems.

I’m sure this is more than anyone wants to know but…

Regarding China, It’s my understanding is that health care availability is still very uneven. Particularly the rural areas have poor facilities and access. The government does have a program that is trying to get surgeries to more children. Also, there are organizations that work all over the world to provide surgery for children with CLCP – http://www.smiletrain.org is one of them. They do a lot of work in China, India and many other countries. They use volunteer surgeons from around the world and also train local surgeons. Our Cleft Team’s Maxillofacial Surgeon mentioned that he spent a couple weeks in China doing surgeries for such an organization.

From the people I’ve meet, it unusual to adopt a child from China with CLCP who’s palate has been repaired, unless they are around 5 or older. Almost always the lip has been repaired, as it was with my son. It’s recommended at about 2-3 months. It’s harder for infants to get enough nutrition without it. My son’s was done at 4 months, so good, considering he’s small. It seems, for optimally results in speech and healing the cleft should be repaired around 8 to 18 months, depending upon health. Our son’s was done with us at 26 months.

Anecdotes from the group of parents with internationally adopted children with CLCP seem to suggest that the surgeries done are generally good quality. Anecdotes also seems to suggest that needs for speech intervention are higher than the 30% average* That is a very unscientific observation though, since parents with speech intervention needs probably interact with the group more. But also not surprising since surgeon seem to generally like earlier palate surgeries because of better speech results.

Regarding self referral. Huh, we actually have the ability to self-refer with our current insurance, but I never do it. With most HMO’s you can’t do it. I can’t imagine it would be something I would miss, as long as I can get referred to the doctor of my preference when needed.

*The general statistic stated of children with CLCP who need speech therapy.

Regarding volunteers for supplying surgeries to children in need. I know there are many other people in the medical profession and outside it besides surgeons who give their time. Didn’t mean to leave anyone out.

micheleinmichigan, you were asking about CLCP surgeries in Canada vs the US for appropriately-timed CLCP surgery. My friend responds:

“For the CLCP, here they schedule surgery per the child’s needs… they don’t go “pick us, we’re better, if you shop around, and we’ll put you on a waiting list and the child will get the surgery … whenever”. Most if not all CLCP kids are followed immediately by the clinic of your choice, and yes, 100% free to go with whomever… I chose to go to Montreal Children’s instead of Ste Justine as they are more easily accessible by metro for me, and anglophone. I just called them up, said I was adopting a CLCP child, and they put him in their files. I got an appointment to see the head of the clinic within a few weeks of him coming home, and we were sent to the ENT, the hearing test, dentist, speech evaluation etc, all within a few weeks or a month or two, and all the info goes back to the cleft clinic. He needs to go every 6 months for the dentist, speech evaluation etc (he passed the hearing test, and doesn’t need any extra surgery on his done in China surgery … he had CL repaired there about 4 months old and CP also repaired, sometime between 13 and 22 months… I have no info, also doesn’t have ear infections, need tubes in his ears or anything or he’d have pretty much immediate followup).

I forget if they called us, or we called them, or if it was the dentist or somesuch, as they are all interrelated and coordinated by a cleft clinic secretary, but we got called in to see the orthodontic surgeon to look at where he is. They gave us the next appointment at the same time, for November. They will continue to follow up with him as his jaw grows (doing xrays to see if his adult teeth are coming in, if they are any missing etc) in order to schedule the bone graft for his gums when his body is mature enough and ready for the bone to be in his jaw for the teeth to grow down into when they come in.

So he has been followed as an adoptive kid from before he came to Canada straight through, and will continue with the same team of ENT, dentist, orthodontic surgeon, I think another surgeon who takes the bone graft from his hip, speech therapist etc, and the surgeries will be scheduled in advance (so of course their is “waiting” but it is like “his teeth will be ready to come in in 8 months, so we want to do the surgery in 4 months so the jaw is healed and waiting”) according to his physiology and growth schedule. Not any administrative “waiting list”. And everything is covered by medicare. No insurance for me to pay, no shopping for an insurance company. “shopping” for a doctor only in that I can chose to go to any cleft clinic that is accessible to me that I chose… I don’t have to compare waiting lists, prices, services etc… as if they were profit ventures.

As far as I know (not having a born here child), a child born here CLCP is the same. From the moment they are born, or it is visible on ultrasounds, the cleft clinic would be contacted, and I believe surgeries are scheduled according to when the child is ready. Ie they do the lip first so the child can breathe properly and keep food in its mouth, and also less aesthetic problems. And secondly they would schedule the palate surgery for when the skin in the palate is grown large enough to properly cover the actual hole (cleft). Here I believe they do both as soon as physically possible for the child. I have never heard of a child running around with an unoperated cleft because of lack of accessibility or waiting lists. In fact here in Canada we very seldom ever see a visibly cleft baby as they are operated so very young, unlike in other countries where they may have charities like Smile Train go in to do cleft surgery clinics, often fixing the disfigured lips of toddlers, preschoolers and even school aged children.

But again, I only have experience as an adoptive parent. So far I am very happy. Just the speech therapy component is lacking with a long long waiting list… the referal we have was supposed to be for 3 months after diagnosis, but they immediately wrote us that there was a year waiting. They were very helpful with suggestions to cover the difference… ie to apply to charities, or govt disabled child programs to cover the cost of private therapy. Taotao was accepted within a few weeks for an “integration into garderie” program and within a couple more weeks was approved with a speech therapist coming in once a week from April to August… would have cost me $125 a week, plus $400 evaluation, but it was all covered by the govt, as soon as we put in an application and found a willing speech therapist. There are very long lists and it is expensive, privately. But then I imagine it is the parent’s choice, and also I believe a lot of people do have insurance at work which will cover this sort of thing (we were asked if we had insurance at work).

There is apparently a shocking lack of speech therapists in Ontario too (was on the CBC radio) and waiting lists are long… which, since most of them are private practices paid big bucks by parents, not part of the state health system, has little bearing on the US vs Canada system.

Does that answer the question? You can perhaps find more on the Montreal Children’s Hospital cleft clinic site.”

We do have private health insurance here in Canada that can be either purchased privately or obtained through the employer’s group plan. But I will tel you that private insurance that has driven woo in many cases.

I don’t know about there, but here group health insurance plans are based largely on the requirements/wishes of the purchasing employer: if the employer wants massage therapy, acupuncture, or bump-reading included as well as drugs and eyeglasses, the insurance company will quote a price and it will be included in the policy.

However, the employer is driven by the wishes and will of the employees (and sometimes by strong Unions such as the teachers union). So when collective bargaining occurs, employees and unions bargain to obtain various types of woo in their group insurance policies.

Employers can maybe add acupuncture or naturopathy relatively inexpensively and it looks like added value to the health plan. Woo becomes institutionalized (“hey, we’ve got coverage for it, so it must be worthwhile, right?”).

Alison, thanks so much for the information and please thank your friend also. I’m glad her son is doing well.

The time line seems very similar to what we’ve had in the States. We chose our clinic before my son’s arrival, called and scheduled an appointment when we got home that was about 3 or 4 weeks from the time we called. His cleft surgery was scheduled at that time for about a month from then. The cleft clinic ENT took a bit longer to get into (can’t quite recall, maybe a couple months), but his ear tube surgery was also scheduled for about a month after his first appoint. Like your friend says, everything else is just waiting for the right time to do procedures.

The speech therapy component sounds different. It sounds like our speech therapist(s) are a bit more intergrated into the medical team. But it’s hard to make a good comparison the systems sound very different in that area. We also have speech offered through the schools and I’m sure availability varies a lot across the U.S.

Regarding choosing the hospital/doctor. I don’t know anyone who does cost of procedure comparisons. People I know who are shopping for care for their child with cleft usually compare Plastic surgeon’s reputation, quality of care at the hospital, of course distance is an issue and availability and cost through your insurance options.

The last is a major pain. The cost of different insurance, the deductibles, the co-pays, the things not covered by certain insurance plans. Ugh. This is, of course, where some of the extra expense of the U.S. medical system lays. The interaction between all those individual insurance companies with their individual codes, coverage restrictions, copays, etc and the medical providers billing departments means a healthy size bureaucracy.

I have group insurance through my employer. It covers medication (by law I have to use group/ employer insurance for medication if I have access to it; otherwise my medication would be covered by the provincial universal medication insurance), dental care, physiotherapy, psychotherapy, vision care, massage therapy, imaging and some other things – possibly including acupuncture.

Medication has a universal private option and so does imaging – sort of. You can get MRIs done free by the public system (which means waiting) or jump the queue and pay cash to a private clinic (which means not waiting). Dental care, physiotherapy, glasses etc. are all out-of-pocket if you don’t have employer insurance.

To weing’s point, we have scads of dental clinics, optometrists, MRI clinics and vets: all completely privately funded with an overabundance of services. However, as my friend points out, private funding is clearly not a panacea because it hasn’t generated an overabundance of speech therapists. And the publicly-funded area works for everyone I know who’s needed it, and overall we pay less for better health.

Alison is right that it’s at least partially private medical coverage that’s driven the rise of woo in Canada. Because almost all private/work related medical coverage covers a fair amount of woo, it encourages people to try things they wouldn’t if they had to pay out of pocket. (Not that I consider massage or dentistry woo – which is not to say both fields aren’t prone to promoting lucrative woo – but most private/work health plans cover chiros and naturopaths as well.)

Having just gotten someone in a state of crisis into the medical system here, I’m actually hugely impressed with how well our system works for people who truly need it and who are willing to engage (and even how good they are with people who are problematic patients). It’s not fancy, there are no bells and whistles, but it works really well in general. Sure you need to pick your hospital according to needs if you can but that’s equally true in the US. (For instance, you’ve got a complex condition to be treated – make sure you go to a teaching hospital where you’re an “interesting mystery” as opposed to being a “lost cause” or “too difficult” at a smaller suburban hospital that doesn’t teach. Or make sure you go to a hospital that’s strong in the specialty you need, etc.) And, yes, there’s triage but I don’t find that as problematic as someone in need being passed by because someone with more money but less urgent need shows up. Triage exists for a good reason, it’s about medical need and prioritizing care based on medical need.

Thanks for the correction Alison – in that case I agree with both of you. While Canadian medical care may be more meat and potatoes than glamorous, I actually think medicine benefits from being practical and treating patients like patients instead of being about selling services to “clients”. Once you’re dealing with “clients”, you’re no longer actually practicing real medicine in my (admittedly very biased) opinion. I think this is particularly dangerous when you get into areas like addiction treatment (now there’s a world of woo! particularly in the US where the AA model seems to predominate), mental health or even more basic treatments and tests. Doctors really shouldn’t be selling their patients anything because, as is recognized by the laws regarding selling drugs, it creates a conflict of interest. And that includes selling procedures (not just medication).

I have read all the comments.I have not heard one person here mention about the controversy concerning pharmaceuticals.All the medical fraud,lawsuits against drugs etc.Contributing to deaths worldwide despite of all the medical hokum scientific studies.I think this discussion is biased.Many medical doctors are stealing people’s hard working money.Misdiagnosing,suppressing symptoms and then treating the side effects with more dangerous drugs.Its only a matter of time until more drugs are recalled.Thing is,how many more people will suffer on the hands of the pharmaceuticals?You all based these discussions here under quackwatch.com.The most controversial site on the internet.Medical doctors themselves say how shameful it is to see such a biased site.Stephen Barrett himself a pseudoscience quack psychiatrist.Which is the biggest quackery.Literally steals money from innocent patients.Make them believe they have an illness,make up diseases eg.If a patient urinates the bed or argues with his/her mother,there is a condition for that and a prescription drug to follow the treatment.What quackery.Depression?I have depressed for three months because of personal reasons,I did not need any bogus drug that can cause me to have suicidal thoughts to feel better.I had family support because it was a “Mind set” Go to You tube and type in psychiatry and you will see the very same medical doctors and 3 psychiatrists exposing the fraud.Stephen Barrett a critic and a team of fraudulent MD’s were sued many times and are not experts in nutrition but claim to be.What a bunch of rubbish.I know many medical professionals who use supplements and therapies along with their conventional techniques and works well with patients.There are so many pharmaceuticals being exposed all around the world as being a fraudulent industry.Harmful side effects,death etc.I don’t know if I have ever heard about Omega 3 causing death though,have you?If so please post a recent unbiased study.People have a right to choose either alternative or conventional.There are many scientific studies concerning supplements but you all have not researched any.Infact the supplement companies are directed by medical doctors and PhD’s in chemistry.Yet other doctors are just critics.If you dont understand how something works,you criticize and make assumptions.No evidence whatsoever to support any claim here concerning complementary medicine.Infact I have sufficient evidence of over a dozen drugs which contributed to serious illnesses and death.People have died under the hands of an MD.Doctor of pharmaceutical medicine,there is a difference.If you have to carry on a discussion concerning a topic,you should not be biased.Be objective because there are alot of fraud in big pharma today.Infact the funny thing is,the very same medical doctors are exposing them.We need to educate the public,especially the young people of society about prevention.Keeping themselves healthy,exercising etc.So they would not have to depend on drugs (Which is really a consumer product)or even supplements.

Doctors, politicians, and the American public all agree that much of healthcare is unnecessary. Unnecessary healthcare is potentially dangerous. There is much disagreement about how to reduce healthcare costs by curtailing unnecessary tests, prescriptions for pills, surgeries, etc. Most doctors who believe in practicing medicine based on proof of effectiveness from scientific method are distressed that healthcare reform has loopholes for CAM. By definition, CAM has never been proven to be better than placebo effect (like a sugar pill). So if healthcare reform is not curtailing unnecessary healthcare, where will the savings be? Will patients still be subjected to the risks of unnecessary healthcare? Will effective treatments be cut back, at the same time we pay for treatments that have never been proved to be effective? Will the government set up a double standard for cost effective medicine? That seems to be the direction we are headed.